Evidence based medicine and evidence based policy

There was a fair bit of media coverage of the finding that teenage-pregnancy-prevention programmes using simulated babies are associated with an increased rather than decreased teenage pregnancy rate. Some of the media discussion focused on the role of evidence in public policy.

Via Twitter, I came across this article on evidence-based policy by Howard White in The Independent

Evidence-based medicine has transformed medical practice. TheCochrane Library has published more than 6,000 studies summarising high quality evidence for health interventions. Notable cases include breast screening, which used to be recommended for women from the age of 40 until the evidence showed that the number of false positives recorded was in fact doing more harm than good. The risks from unnecessary surgery were greater than the often small benefits from early treatment forbreast cancer.

Hormone replacement therapy (HRT) is another example. It was routinely used to reduce heart disease, but then became far less common when evidence showed adverse effects. There is now a more nuanced understanding of which women will benefit from HRT and which will not.

Prior to Cochrane, doctors based their advice on out-of-date knowledge, personal experience and the influence of drug reps. Today, doctors have access to evidence-based guidelines. Decisions on what the NHS can and should fund are informed by the advice of the National Institute for Health Clinical Excellence after a review of the evidence.

So why can’t we do the same for social and economic policy?

For those who are interested, I engaged (or am engaging) in a twitter exchange on this with Howard White, whose replies have been very gracious. As in so many of these exchanges I suspect that we agree on more than we disagree on (and possibly agree on everything with a difference in emphasis)

Of course policy should be based on evidence, where available. This not only seems extremely reasonable and  rational – it is eminently reasonable and rational. I also write as an admirer of the Cochrane Collaboration.

However, I always feel a sense of caution when clinical concepts are introduced into political discourse. The best definitions of EBM always include the word “judicious”, as here

“Evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients.”

Judicious is key – judgment and reflection are required. Does this body of evidence apply to my patient, this individual person in front of me, or does it not? As I wrote on another point:

it is one thing to have an evidence base for a specific therapy in medical practice, quite another for a specific intervention in society itself.

My review of Helen Pearson’s The Life Project is still to be published, when it does I will perhaps write a little more on “evidence-based policy”, a concept which began to enjoy great vogue in the 1990s.What Pearson’s book shows, however, is that the devil can cite evidence for his own purpose; “evidence” can be wielded with agendas.

Obviously the Campbell Collaboration aims to address this, by being transparent about the evidence used and the methodology used to synthesise it.

A further point is that evidence-based policy tends to presuppose consensus on the ends of policy  – and emphasise technocratic means of getting there. Thereby the focus on specific interventions, rather than any wider sense of not merely social goals but of social meaning. Of course, this very much in keeping with a time in which we are all supposed to be beyond “grand narratives” – which is of course itself a “grand narrative.” I would suggest that many recent events in politics around the world are best understood as testing this notion to destruction.

Bringing it all back to a question I asked a while ago about the best kind of evidence for health informatics innovations, perhaps what this illustrates is that the way we do evidence now tends to be to focus on specific interventions and, as far as possible, measure their effects as specific interventions and without reference to an overall system. Indeed, this is obviously necessary for assessing therapies and treatments. But is it necessarily missing something when it comes to a system?

A walk in the woods – the rise of “forest bathing”

In recent times there has been increasing media attention on the Japanese practice of shinrin-yoku  or “foresting bathing.” Going for a walk in a forest – which is what forest bathing basically is – is something I have always both enjoyed and found restorative.  And anything that encourages people to connect with the environment around them is to be welcomed. And there is a body of research showing health benefits (though it strikes me that studies with 12 subjects are rather small to be making too many generalisations, and obviously forest bathing is something which a plausible placebo for comparison is tricky to devise!)

More generally I am a little wary of using health grounds alone as the reason to engage with the natural world. This is not to say this is an invalid approach, or one which has not got its place in a therapeutic toolkit. I would not use the much-abused term “medicalisation” in this case, but rather perhaps “therapeutisation” – and relate it not so much to a need to describe more and more human phenomena in clinical terms (which is what medicalisation is) but to a need to justify pleasurable and meaningful activity by an appeal to health and to “the evidence.”

 

For one thing, evidence can change, and one wonders if larger studies would find the same benefit (and as is clear from the first paragraph, while I am very well disposed to forest bathing as an activity, I would be slightly sceptical of some the full evidential weight of the studies being cited). It is well recognised that therapies which initially show great success in specific groups do not necessarily scale to larger groups, and sometime hype can damage their reputation unfairly.

“Forest bathing”, in the West at least, seems part of a larger trend towards casting activities as mindfulness practices – we see this with adult focused colouring books and other practices which people essentially enjoy and find provides an alternative focus to the information-saturated world of devices. I am professionally and personally very well disposed to this and other approaches to mental health that emphasise meaningful activity. I would also strongly feel that activities are most meaningful, most enjoyable and (ironically given the point I am making) most beneficial when they are pursued for their own sake or in pursuit of their own objectives and (to use a very overused word) values.

Photos are from Glen Wood, near Kilsheelan (and just across the Suir in Co Waterford)

“Nitrazepam made dreams everydayish” – searching for “dreams” in the BJPsych

Following on from  my recent posts about dreams and psychiatry (and the changes in how psychiatrists engage in questions of the meaning of symptoms reported to them) I have just searched the British Journal of Psychiatry site using the word “dreams”. As the BJPsych is the journal of the Royal College of Psychiatrists and the third most cited psychiatry journal in the world, it is fair to regard it as reflecting contemporary psychiatry.

 

Using the “Best match” search criteria,  the top 10 results  for “dreams” are all from other decades – with the most recent being from 1974 – a paper which dealt with the impact on dreaming of then-commonly-used sleeping tablets. Haven’t read the full paper yet, but here is the abstract (and I haven’t come across the word “everydayish” before!) :

It was predicted that amylobarbitone and nitrazepam would make dreams less active, and withdrawal would make them especially intense. Dream reports were collected from subjects before, during and after chronic administration of either of the two drugs or placebo. Dreams were rated as conceptual or perceptual, and as visually active or passive. They were also rated for hostility, anxiety, sexuality, psychotic thinking, bizarreness and degree of reality. A variety of other measures of content were made, such as the number of characters, activities, social interactions and emotions in each dream report. An experienced, `blind’ judge tried to assign reports according to whether they came from baseline, drug or withdrawal conditions. Subjective estimates of dreaming were also collected.

Contrary to prediction, dreams were virtually indistinguishable under the three conditions. Two effects were that nitrazepam made dreams everydayish and its withdrawal made them bizarre, and withdrawal of amylobarbitone produced exceptionally vivid dreaming and nightmares at home but not in the laboratory. Consideration of the results suggests that these hypnotics affect the quality of thought processes in sleep, and that in clinical use their withdrawal would be expected to produce unpleasant, anxiety-filled dreams and nightmares.

 

The number 1 result is from 1962. Again I hope to read the actual paper but here is the abstract, again rather “of its time”:

Spoken personal names which were randomly presented during the rapid eye movement periods of dreaming were incorporated into the dream events, as manifested by the ability of the experimental subjects and an independent judge subsequently to match correctly the names presented with the associated dreams more often than would be expected by guessing correctly by chance alone. Incorporation of emotional and neutral names into the dream events occurred equally often. The manner in which the names appeared to have been incorporated into the dream events fell into four categories of decreasing frequency: (a) Assonance, (b) Direct, (c) Association, and (d) Representation. Perceptual responses to the stimulus names, as manifested by subsequent dream recall, occurred without any accompanied observable differential electroen-cephalographic or galvanic skin responses compared with those occasions on which no such perceptual responses were evident. The frequency of recall of colour in dreams was higher than has been previously reported.

The results are discussed in relation to the function of dreams and perception during dreaming.

Using the “Newest first” search criteria does throw up more recent results, but in most of the top 10, the word “dreams” is not referring to a subject of clinical or research interest. The number one result is an article in which a psychiatrist discusses ten books that influenced him. The next result uses “dream” in the sense of “hope” or “aspiration”:

 

The National Institute of Mental Health (NIMH), under the leadership of Thomas Insel, powerfully steered national and international researchers, policy makers and research commissioners to buy into a hopeful dream that one day the basic sciences will afford opportunities to prevent and treat mental illness at its root cause

Of the rest of the “Most recent” top ten, we have three poems, one film review, another “Ten Books” feature, one paper whose mention of dreams is in passing as an adverse drug effect, and just two papers which, from my brief reading, dreams seem to feature as a topic of clinical interest. Both are papers in child psychiatry and both deal with dreams in the context of psychotic phenomena:

 

It has been suggested that there may be shared patterns of neuroanatomical, neurochemical and neurophysiological pathways occurring in nightmares and the positive symptoms of psychosis, for example, the finding that cortical dopamine levels are raised during nightmares⁴¹ and the functional significance of sleep spindles in psychosis⁴² that are consistently reduced in schizophrenia.⁴³ Some studies have also reported a continuity between dreams and psychotic experiences; with overlapping content⁴⁴ and indistinct barriers between these experiences.⁴⁵ This is related to the increased interest in dreams⁴⁶ or REM sleep⁴⁷ as a neurobiological model for schizophrenia or psychotic phenomena.

Here to, we see that interest in dreams is confined to their possible utility as a model for psychosis – an interesting topic, but one from which issues of “meaning” are excluded.One of this paper’s references is worth reviewing – and I find it  interesting that a projective test (the TAT) was used in this study:

Many previous observers have reported some qualitative similarities between the normal mental state of dreaming and the abnormal mental state of psychosis. Recent psychological, tomographic, electrophysiological, and neurochemical data appear to confirm the functional similarities between these 2 states. In this study, the hypothesis of the dreaming brain as a neurobiological model for psychosis was tested by focusing on cognitive bizarreness, a distinctive property of the dreaming mental state defined by discontinuities and incongruities in the dream plot, thoughts, and feelings. Cognitive bizarreness was measured in written reports of dreams and in verbal reports of waking fantasies in 30 schizophrenics and 30 normal controls. Seven pictures of the Thematic Apperception Test (TAT) were administered as a stimulus to elicit waking fantasies, and all participating subjects were asked to record their dreams upon awakening. A total of 420 waking fantasies plus 244 dream reports were collected to quantify the bizarreness features in the dream and waking state of both subject groups.

Two-way analysis of covariance for repeated measures showed that cognitive bizarreness was significantly lower in the TAT stories of normal subjects than in those of schizophrenics and in the dream reports of both groups.

The differences between the 2 groups indicated that, under experimental conditions, the waking cognition of schizophrenic subjects shares a common degree of formal cognitive bizarreness with the dream reports of both normal controls and schizophrenics. Though very preliminary, these results support the hypothesis that the dreaming brain could be a useful experimental model for psychosis.

 

Vampirism as Mental Illness: Myth, Madness and the Loss of Meaning in Psychiatry

This  is certainly the academic paper I have been involved with which has garnered the most media attention. Brendan Kelly and myself intended to write a nuanced paper on how psychiatry conceptualised vampirism, when it occurred as a clinical presentation, and how this changed over time. This reflected wider changes in psychiatry (and probably, though this wasn’t part of the paper, society itself) in that the meaning ascribed to symptoms was increasingly devalued in favour of a “checklisting” approach. Something similar has happened to dreams, in the psychiatric context.

Did we succeed in this? Here is the abstract :

 

Vampirism, as a clinical presentation, was formerly much discussed in psychiatric literature. In recent years this has not been the case. This article begins by exploring the history of vampiric phenomena and the various medical theories of vampirism. It discusses the change in emphasis in psychiatry from a psychotherapeutically-influenced exploration of the meaning of a particular symptom to a more ostensibly evidence-based, checklist approach. This reflects a wider shift in psychiatric culture. Articles from the psychiatric literature dealing with vampirism are reviewed in depth. The article argues that the clinical interpretation of vampirism may be useful as an indicator of shifting attitudes within psychiatric discourse.

And here is how The Sunday Times covered the article:

Perhaps not that surprisingly, this provoked a backlash from the online vampyre community, none of which seemed based on actually reading our article but on the Sunday Times and Irish Central’s even more misleading take. (most of the links to the vampyre forums where we were attacked seem to have broken.

Brendan has talked further about the paper in various forums such as here , and has discussed this media and online reaction.

I know How Journalism Works. I know that the headline is chosen by a subeditor, not the author of the article. I know that “Doctors write nuanced article on changes in how psychiatrists see vampires over time” is not a headline.

In a way, this coverage illustrates that for the media as well as in day to day a life, a psychiatrist is character with a somewhat predetermined role and that, if a psychiatrist is writing about vampirism, it must be through the prism of mental illness and of treatment. Even in cases where the psychiatrist is trying to do the direct opposite. Alasdair MacIntyre wrote (quoted in the blog post linked immediately above):

Contrast the quite different way in which a certain type of social role may embody beliefs so that the ideas, theories and doctrines expressed in and presupposed by the role may at least on some occasions be quite other than the ideas, theories and doctrines believed by the individual who inhabits the role.

 

 

Asking about dreams

A while back I blogged a brief note about sleep and dreams, essentially discussing my own interest in sleep and noting that at the current historical moment, for the first time “sophisticated” people don’t take dreams in any way seriously. As I wrote then:

The contemporary medical/scientific conception of dreams is that they are either meaningless or at most reflect the emotional state of the dreamer. This is one of the most dramatic breaks with most of human history, during which dreams were seen as messages from the Divine, or or prophetic. Freudian dream interpretation – with its idea that dreams are the Royal Road to the Unconscious – was perhaps, despite Freud’s atheism, the apotheosis  of the significance of dreams in culture.

A vivid, detailed, and somewhat disconcerting dream last night (no, I won’t bore you with the details – unless supremely well executed, the i-had-this-dream story sits with I-was-so-drunk or I-was-so-high or I-was-backpacking-being-such-a-traveler-not-a-tourist storiy in a pantheon of the ultimate stories inflicted by bores) made me think of this again.

It is not strictly true that contemporary psychiatrist don’t ask about dreams – quite often it is a manifestation of PTSD. In that context, however, in my experience it is very much a “checklisty” phenomenon. There are some interesting papers on dreams in PTSD, especially the paradox that dreaming is often posulated to help process traumatic and other events, yet nightmares are a feature of PTSD. Papers on drug dreaming also appear in the recent literature, as does this this paper on dreams in people with a diagnosis of personality disorder.

I want to avoid being too dogmatic about my sense that this contemporary literature is very much functional in its approach to dreaming – not ascribing any particular meaning to it. The literature is no doubt richer than the above links alone would suggest. This is an area in which a thorough literature search would have to be especially well designed – think of how many synonyms and variations of “dreams”, “dreaming”, “nightmare” in so many languages one would have to do to do it properly, and is therefore beyond the scope of a blog written in fugitive time of the early morning. However, I do feel confident enough to comment that the content of dreams are rarely explored in contemporary psychological or psychiatric practice. The increasing influence of CBT both within mental health practice and in the wider culture leaves little room for issues of the meaning of dreams.

 

Nabokov and epilepsy

Currently I am reading Colin Grant’s A Smell of Burning: The Story of Epilepsy for review. As it happens, I open the TLS webpage  this morning and come across this article on whether Vladimir Nabokov had a form of epilepsy. Galya Diment, the author of the piece, is certainly a careful reader of Nabokov:

I write about Nabokov and teach him every year, which means that I constantly re-read him (“One cannot read a book”, Nabokov famously advised his students; “one can only re-read it”). And certain passages in his autobiographical and fictional writings – amounting overall to a kind of obsession – started to come into sharper focus: he, too, must have suffered from some form of epilepsy.

 

I am always a little wary of attempts at retrospective diagnosis. This is especially so in psychiatry, where a trawl through a writer’s journals will almost certainly reveal introspective passages that can be spun as depressive, or ecstatic passages that can be spun as manic, etc. etc. It can also lend itself to a form of nothing-buttery; Philosopher X’s thought is best understood as HE HAD ASPERGER’S SYNDROME.Politician X’s acts are best understood as HE WAS A PSYCHOPATH. While there can be some interesting insights from this kind of thinking, retrospective diagnosis can only be part of a story, and to my mind a relatively small part. I have written about this at more length and in a more academic setting before. And this kind of things is not confined to psychiatry.

One of the fundamental issues in retrospective diagnosis is simply this; a doctor in practice wouldn’t make a diagnosis without seeing a patient, “taking the history”, doing some form of examination etc. So why suspend this principle for a case in which the patient is dead, possibly a very long time?

In fairness Galya Diment’s TLS piece of Nabokov is more nuanced than other examples of the genre, although this passage is fairly typical of mining the literary data for hints of a diagnosis:

Since there are no medical records available, the best sources of relevant clues are of course Boyd’s biography and Nabokov’s personal letters. Boyd lists the following known health problems that the writer apparently suffered from: “adenoma . . . concussion . . . heart palpitations . . . influenza/pneumonia . . . intercoastal neuralgia . . . lumbago . . . lung damage . . . nervous strain . . . pleurisy . . . psoriasis . . . shadow behind the heart . . . sunstroke . . . urinary tract infection . . .”.The “nervous strain” is particularly intriguing, since it is so vague. “Volodya has had a kind of nervous breakdown, due to overwork”, Edmund Wilson wrote in 1946 to their mutual friend, Roman Grynberg, the editor of Russian émigré journals. In 1952 Nabokov himself wrote to Grynberg, that his state of health was such that his nervous system only just then “had stopped resembling tangled barbed wire” (“перестала походить на спутанную колючую проволоку”), which is quite reminiscent of Kinbote’s characterization in Pale Fire of Shade’s clusters of epileptic seizures as “a derailment of the nerves at the same spot, on the same curve of the tracks, every day, for several weeks, until nature repaired the damage”.

“I was so joggy and jittery and buzzy with insomnia and so forth”, Nabokov complained to Wilson the following year, “that I decided to lay aside Pushkin for a few months.” “Pushkin” was his translation ofEugene Onegin, and he was already working on Lolita by then as well. There was definitely enough labour and anxiety there – as there had surely been in 1946, and in 1952 – to cause much general stress, but the way he describes it – “joggy and jittery and buzzy” – is also a perfect characterization of epileptic events.

 

The evidence Diment marshals  includes some family history (his cousin Nicolas Nabokov) and some features possibly (only possibly) linked epilepsy :

Nabokov shared his synaesthesia – “coloured hearing” and seeing letters in colours – with his mother; it occurs, we are told, in at least 4 per cent of temporal lobe epilepsies. He also apparently shared with her, as he reveals in the same chapter, “double sight . . . premonitions, and the feeling of the déjà vu”, all three definitely characteristic of epileptic seizures.

“Definitely characteristic” may be accurate, but “characteristic” does not mean diagnostic. At times Diment acknowledges the weaknesses in her argument:

Nabokov knowing or suspecting he had epilepsy may also explain why he never drove a car. Back in the 1940s when the Nabokovs bought their first American automobile, people diagnosed with any form of epilepsy, including the mildest, were routinely prevented from having a licence. I should note, however, that it is probably equally likely that – as most Nabokov memoirists and biographers suggest – he simply proved to be a talentless learner and, in general, preferred to be chauffeured by his wife, Véra, just as he and his family had been chauffeured in St Petersburg and Vyra, where they spent the summers.

Perhaps the most interesting – and in its way possibly more convincing than other pieces – element of her argument is that Nabokov would have concealed his seizures. A strong theme of what I have read so far of Grant’s book is stigma – not entirely historical – of epilepsy. As is clear from the above, I am something of a sceptic of retrospective literary diagnosis – but what Diment’s article illustrates very well is Nabokov’s extraordinarily specific ability to describe certain states of mind and experiences that hover between the mental and physical.

War! What is it good for? Mobile mental health apps, apparently.

OK, the temptation to quote Edwin Starr is irresistible in this context. It is often stated that wars concentrate and accelerate technological development, although this can be debated. Often you see long lists (such as in the first post of the Quora discussion linked to above) of innovations and developments which accompanied major wars. The Manhattan Project was the ultimate Big Science project.

However, as one Quora contributor, Robin Daverman, observes:

War advances military science and technology at the expense of other science and technology.

Atomic bombs, poison gas, biological weapons all had the greatest advancement during wars.

High-yield crop development, cancer research, alternative energy, all advanced during peaceful times.

Even IT technology, even though it was originally developed by the military, it would never have been made available to average consumers if the U.S. is still at war. Why would you leak computing technology to potential enemies if you are still at war?

Or another, Paul Hsieh:

Technology definitely advances. Governments will sometimes pour money into it during war. Computers were developed this way. Obviously war machines are invented because of war.

I am not sure there is good evidence of science being developed during war time as compared, for example, to peace time.

Making the atomic bomb is not science. It was an application of recently developed science; it was just engineering. Contrarily, if we look at Archimedes fulcrum law, or Copernicus’ heliocentrism, or Galileo’s observations, or Newton’s laws, or Einstein’s special relativity — these things have nothing to do with war.

All of this is prompted by my discovery that the Virtual Hopebox, a mobile app which is often recommended to service users in my own practice, is a product of the National Center for Telehealth and Technology (T2), a US Department of Defense Center of Excellence for Psychological Health and Traumatic Brain Injury.

The T2 website has lots of interesting stuff, from a good, solid piece on the need to evaluate mobile mental health tools to how to use techniques from dolphin training for achieving goals. T2 evidently have  a focus on PTSD and the site, and the existence of the Virtual Hope Box itself, shows the reality that psychiatric casualties now have a massive impact on military veterans themselves and also the US’ ability to make war. Things have come a long way since General Patton

 

I tend to agree with Paul Hsieh’s comment quoted above that war is “good” for technology but not for science, and that war is “good” for some kinds of technology and not for others. The issues of PTSD, psychiatric casualties and the ethics of military psychiatry themselves deserve longer consideration. For the moment, it is interesting to note the military contribution to mobile mental health apps.